The interpretation of

leukogram in dog and cat

> Abstract
Leukogram includes total and differential white blood cell counts, as well as leukocyte
Kritsepi-Konstantinou Maria morphology. Appropriate blood sampling and handling are essential for the validity
DVM, PhD, Associate Professor, of the leukogram interpretation. Leukocytosis and leukopenia are associated with
Diagnostic Laboratory,
physiologic or pathologic conditions. From a clinical point of view, neutrophilia,
School of Veterinary Medicine,
Faculty of Health Sciences, A.U.Th., neutropenia, lymphocytosis, lymphopenia, monocytosis and eosinophilia are considered
Thessaloniki, Greece the most important alterations in leukocyte numbers. Neutrophilia and monocytosis
usually accompany inflammatory diseases, but they are also observed in excess of
Oikonomidis Ioannis L. steroids. Additionally, neutrophilia can be physiologic, as well as, lymphocytosis, which
DVM, PhD student, is further associated with chronic inflammatory diseases. Eosinophilia typically occurs in
Diagnostic Laboratory, hypersensitivity reactions and parasitisms. Neutropenia is mainly related to infectious
School of Veterinary Medicine,
diseases, while lymphopenia is usually steroid-induced or related to acute infectious
Faculty of Health Sciences, A.U.Th.,
Thessaloniki, Greece diseases. Monocytopenia, eosinopenia, basophilia and basopenia have limited
diagnostic significance. Common morphologic changes of the leukocytes include
the presence of immature, hypersegmented or toxic neutrophils, as well as reactive
lymphocytes and various leukocyte inclusions. These may be of infectious origin, such
as morulae of Ehrlichia canis and Ehrlichia ewingii or of non-infectious origin, such as
siderotic inclusions.

> Introduction
Leukogram is part of the complete blood count (CBC) and includes total and differential
white blood cell (WBC) counts and WBC morphology evaluated during the microscopic
of stained blood smears (Table 1). Appropriate blood collection, sample handling and
storage are essential in order to maximize the reliability of the results. Overnight fasting
Corresponding author: should precede blood collection; the animal must not be under stress and the forma-
Maria Kritsepi-Konstantinou, tion of platelet clumps should be avoided.1 Blood smear preparation should be done as
Diagnostic Laboratory,
School of Veterinary Medicine,
soon as possible and certainly within 2-3 hours after blood collection, while CBC should
Aristotle University of Thessaloniki, be completed within 24 hours, provided that blood into the EDTA tube has been stored
11 Stavrou Voutyra St., in the refrigerator.1 Finally, blood smears are stained with Romanowsky-type stains (e.g.
54627 Thessaloniki, Greece
E-mail: mkritsep@vet.auth.gr
Giemsa, Wright, Diff-Quik) for routine examination.
Tel: + 30 2310 994523
FAX: + 30 2310 994511

> Neutrophilia and neutropenia

Keywords Neutrophilia is defined as the increase in circulating neutrophils and is generally charac-
terized as physiologic, steroid-induced or associated with inflammation and neoplasia.
Physiologic neutrophilia (also called pseudoneutrophilia) is the result of the endog-
• Leukocyte morphology
• Leukocytosis enous release or exogenous administration of catecholamines.2 Physiologic neutro-
• Leukopenia
• White blood cells

62 Ιατρική Ζώων Συντροφιάς • Τόμος 5 • Τεύχος 2 • 2016


Table 1. Leukogram reference intervals.3
Analytes Canine reference intervals
White blood cells (10 /μL)
3
5,0-13,0
Segmented neutrophils (103/μL) 2,7-8,9
Band neutrophils (10 /μL)
3
0-0,3
Lymphocytes (103/μL) 0,9-3,4
Monocytes (103/μL) 0,1-0,8
Eosinophils (103/μL) 0,1-1,3
Basophils (103/μL) 0-0,1
philia is transient, as it occurs within minutes of the
stimulus appearance and generally resolves within
30 minutes.3 It is characterized as mature and mild
to moderate, and it mainly concerns young animals
and especially cats.4,5 Steroid-induced neutrophilia
could be of endogenous (severe stress or hyper-
adrenocorticism) or of exogenous (administration
of glucocorticoids) origin.2,4 It is mature, mild to
moderate occurs within 4-8 hours after the release
or administration of glucocorticoids and resolves
within 24 hours.2,4 However, in chronic therapy with
glucocorticoids, neutrophilia persists for some days,
but it is of lesser degree.6 Apart from neutrophilia,
glucocorticoids have multiple effects on leukogram
(see lymphopenia, monocytosis, eosinopenia). In-
flammation is a common cause of neutrophilia.
Depending on many factors, such as the underlying
etiology, duration and bone marrow responsive-
ness, neutrophilic leukocytosis varies on severity
and can be seen concurrently with left or right shift,
lymphopenia or lymphocytosis, eosinophilia or eo-
sinopenia and monocytosis.7 The etiology of inflam-
matory neutrophilia includes many infectious (most
commonly bacterial) and non-infectious (most
commonly immune-mediated) diseases of inter-
nal or subcutaneous tissues, whereas inflamma-
tion of the central nervous system, intestine, lower
urinary tract and superficial cutaneous tissue may
not induce neutrophilia.2,4,6 Specific inflammatory
diseases (e.g. peritonitis, pyothorax, pyometra) are
associated with leukemoid response. Leukemoid re-
sponse or reaction is defined as an extreme inflam-
matory “leukemia-like” leukocytosis.2 Typically, circu-
lating neutrophils are 50.000-100.000/μL and severe
left shift is usually observed.4 Neoplasia-associated
neutrophilic leukocytosis can be seen in the rare
case of chronic granulocytic leukemia or as a para-
neoplastic syndrome that accompanies benign or
malignant neoplasms, such as rectal adenomatous
polyps or renal tubular carcinomas, respectively.8,9
In dogs, mature neutrophilia may also be observed
during pregnancy.6
Neutropenia is defined as the decrease in circulat-
ing neutrophils and is less frequent than neutrophil-
The interpretation of leukogram in dog and cat
Feline reference intervals
5,4-15,4
2,3-9,8
0-0,3
0,9-5,5
0-0,8
0-1,8
0-0,2
ia. Infectious diseases, such as parvoviral enteritis
and ehrlichiosis in dogs and panleukopenia, feline
leukemia virus (FeLV) and feline immunodeficiency
virus (FIV) infections in cats, induce neutropenia
through bone marrow hypoplasia/aplasia.4-6 Addi-
tionally, overwhelming bacterial infections, endo-
toxemia and septicemia may also be responsible
for neutropenia in both dogs and cats by increasing
the margination or emigration of neutrophils.2 My-
elophthisis, due to primary or metastatic neoplasms
of the bone marrow and myelodysplasia, usually
seen in FeLV positive cats, are causative factors of
neutropenia that usually persists and may be ac-
companied by other cytopenias.6,7 The repeated or
prolonged administration of specific drugs has also
been reported to cause neutropenia due to bone
marrow suppression. Estrogen of exogenous or en-
dogenous (e.g. Sertoli cell tumor) origin, after initial
neutrophilia, and chemotherapeutic agents, such as
doxorubicin, cyclophosphamide and vincristine, are
related to predictable toxicity, while cephalosporins,
phenylbutazone, griseofulvin are examples of drugs
that are related to idiosyncratic toxicity.2 Radiation
therapy has also been associated with neutropenia
due to the destruction of bone marrow hematopoi-
etic cells.2
> Eosinophilia and eosinopenia
Eosinophilia is defined as the increase in circulat-
ing eosinophils. Parasitism is the most common
cause of eosinophilia.10 Both ectoparasites (e.g. fleas
and ticks) and endoparasites (e.g. helminthes) are
responsible for the increase in the number of eo-
sinophils.10 Moreover, parasites that invade the tis-
sues, including those which migrate through them,
induce greater eosinophilia.6 Hypersensitivity dis-
orders, such as allergic dermatitis and food or drug
allergies, typically result in migration of eosinophils
to the affected tissue; thus, initial eosinopenia is
followed within a few days by eosinophilia due to
bone marrow response.6 Apart from hypersensitiv-
ity disorders, other inflammatory agents acting in
Hellenic Journal of Companion Animal Medicine • Volume 5 • Issue 2 • 2016 63
 The interpretation of leukogram in dog and cat
Figure 1. Feathered edge of a
blood smear from a dog. Many
band neutrophils are observed.
Giemsa, 63x objective.
tissues rich in mast cells (the respiratory system,
alimentary system, genitourinary system and skin)
have been correlated with increased numbers of
circulating eosinophils.6,7 Eosinophilia has also been
associated with idiopathic eosinophilic conditions
(e.g. hypereosinophilic syndrome in cats), as well
as with neoplasms, either as a paraneoplastic syn-
drome (e.g. mast cell tumors) or in rare cases of
chronic granulocytic leukemia.7,11,12
Eosinopenia is defined as the decrease in circulat-
ing eosinophils. Eosinopenia is of little diagnostic
significance and is mainly the result of high gluco-
corticoids concentration.
> Basophilia and basopenia
Basophilia is defined as the increase in the circulat-
ing basophils, although to be clinically significant,
it should be of a great degree or of extended dura-
tion.2 An increase in basophil numbers typically oc-
curs along with eosinophilia in cases of parasitism,
hypersensitivity disorders and neoplasia and is rare
in clinical practice, while its most common cause by
far, is dirofilariasis.4,5,13
Basopenia is defined as the decrease in circulating
basophils, but practically it is undetectable and of
no diagnostic significance.
64 Ιατρική Ζώων Συντροφιάς • Τόμος 5 • Τεύχος 2 • 2016
> Lymphocytosis and
lymphopenia
Lymphocytosis is defined as the increase in circu-
lating lymphocytes. Lymphocytosis is associated
mostly with acute stress response (physiologic lym-
phocytosis), chronic inflammation, neoplasia and
hypoadrenocorticism. Physiologic lymphocytosis is
an effect of endogenously released or exogenously
administered catecholamines and is observed con-
currently with neutrophilia. Chronic inflammatory
lymphocytosis is part of the hyperplastic lymphoid
response to chronic antigenic or cytokine stimula-
tion seen in many bacterial, viral, fungal and proto-
zoal infections.2,14,15 Ehrlichiosis, leishmaniosis, babe-
siosis and FeLV infection are some examples that are
frequently seen in clinical practice.14-17 It is usually
of mild to moderate degree and is commonly ac-
companied by neutrophilia and/or monocytosis
and occasionally by eosinophilia and/or basophilia.2
Chronic lymphocytic leukemia/small cell lymphoma
stage V is associated with lymphocytosis, which can
be marked with or without the evidence of atypical
lymphocytes in peripheral blood.18 Both dogs and
cats suffering from hypoadrenocorticism may show
lymphocytosis due to the lack of glucocorticoids.19
Finally, it should be taken into consideration that
puppies and kittens normally have higher number
of circulating lymphocytes than adults until the age
of 2 and 4-5 months, respectively.2,6

Lymphopenia is defined as the decrease in circulat-
ing lymphocytes. It can be steroid-induced, acute
inflammatory and due to limited production or loss
of lymph. Steroid-induced lymphopenia due to ex-
ogenous or endogenous glucocorticoids is the re-
sult of the shift of lymphocytes from the circulating
pool. In general, the severity and duration of lym-
phopenia are proportional to the glucocorticoids
dose and duration of their increased concentration.2
Acute inflammatory lymphopenia is typically ac-
companied by neutrophilia or neutropenia; in such
cases, the resolution of lymphopenia is believed to
be a good prognostic factor.2 The etiology includes
the early stages of many acute viral infections (e.g.
canine parvoviral enteritis, canine distemper, FeLV
infection) and acute, severe or overwhelming, sys-
temic bacterial infections.2,3,6 Lymphopenia can also
be the result of either limited production due to
lymphoid hypoplasia or aplasia, or loss of lympho-
cyte-rich lymph, as seen in chylothorax and protein-
losing enteropathies.4-5
> Monocytosis and
monocytopenia
Monocytosis is defined as the increase in circulat-
ing monocytes. Monocytosis is usually seen concur-
rently with steroid-induced neutrophilia in dogs, as
well as with inflammatory neutrophilia.18 Marked
The interpretation of leukogram in dog and cat
Figure 2. Blood smear from
a dog. One hypersegmented
neutrophil (arrow) is observed.
Giemsa, 100x objective.
monocytosis (when there are not many abnormal
or atypical monocytes) is also a feature of mono-
cytic or myelomonocytic leukemias.2 Monocytosis
along with lymphopenia and eosinopenia may de-
velop with age.6
Monocytopenia is defined as the decrease in circu-
lating monocytes. In health, monocyte numbers are
very low and, practically, monocytopenia has no di-
agnostic significance.
> Mastocytemia
Mastocytemia is defined as the presence of mast
cells in peripheral blood. One mast cell in the blood
or buffy coat smears can set the diagnosis of mas-
tocytemia, as mast cells are not found in blood of
healthy dogs and cats.2 The etiology of masto-
cytemia in dogs includes inflammatory diseases,
regenerative anemias, trauma and neoplasms (mast
cell tumor and other neoplasms).20,21 On the other
hand, circulating mast cells are very infrequent find-
ing in cats and are strongly associated with visceral
mast cell tumor.22
> Leukocyte morphology
The evaluation of blood smears stained with a
Hellenic Journal of Companion Animal Medicine • Volume 5 • Issue 2 • 2016 65
 The interpretation of leukogram in dog and cat

Figure 3. Blood smear from

a dog with presumptive acute
myeloid leukaemia with
differentiation (AML-M2). Four
blast cells are noticed. Giemsa,
100x objective.

Romanowsky-type stain is an essential part of the be either regenerative or degenerative. Regenera-

CBC, especially when automated blood counts re-
veal leukocytosis, leukopenia or abnormalities in
the differential WBC count. For this reason, a manual
differential leukocyte count is necessary in order
to determine the relative numbers of WBCs in the
blood.23 Abnormal findings during the microscopic
examination of the blood concern the nucleus (e.g.
hyposegmentation, hypersegmentation) and/or
cytoplasm (e.g. toxic changes, inclusions) of WBCs.
The morphologic changes of WBCs, which will be
described in the following part, are left and right
shift, toxic neutrophils, reactive lymphocytes and
WBC inclusions.
Left shift (or shift to the left) is defined as an increase
in concentration of circulating non-segmented
neutrophils above 1,000/μL or 10% of total WBC
count in the presence of leukopenia.24 Band neu-
trophils are mostly observed (Figure 1), but if the
demand for neutrophils in tissues is so great, more
immature cells, such as metamyelocytes, myelo-
cytes and even promyelocytes (rarely though) may
be present in the blood.18 A left shift is often asso-
ciated with an acute inflammatory process and its
severity is proportional to the degree of the im-
maturity of neutrophils and concentration of non-
segmented neutrophils in the blood.2 Left shift can
tive left shift is characterized by neutrophilia, more
segmented neutrophils than non-segmented, and
is considered as an appropriate response, whereas
degenerative left shift is characterized by normal or
slightly increased neutrophil numbers in the blood,
less segmented than non-segmented neutrophils
and is considered as an inappropriate response,
suggestive of a guarded or poor prognosis.4
Right shift (or shift to the right) is the increased con-
centration of hypersegmented neutrophils (neutro-
phils with five or more nuclear lobes) in peripheral
blood (Figure 2). By far the most frequent cause of
right shift is the release or administration of gluco-
corticoids, which causes a decrease in neutrophil
emigration.2 Furthermore, it should be taken into
consideration that the delay of blood analysis leads
to right shift due to the in vitro aging of the blood
cells.
Toxic neutrophils are neutrophils (mature or imma-
ture) that have one or more of the following fea-
tures: foamy cytoplasm, diffuse cytoplasmic baso-
philia, cytoplasmic Döhle bodies (but may be seen
in healthy cats), asynchronous nuclear maturation,
very large dimensions (giant neutrophils) and toxic
granules (primary granules that are present after the
promyelocyte stage).2,3 These morphologic changes

66 Ιατρική Ζώων Συντροφιάς • Τόμος 5 • Τεύχος 2 • 2016


are developed in the cells of bone marrow; they oc-
cur due to expeditious neutropoiesis and represent
maturation defects.18 The presence of toxic neutro-
phils in the blood is generally related to left shift and
the more severe the toxic changes are, the poorer
the prognosis.16 Toxic neutrophils are usually associ-
ated with bacterial or viral infections, immune-me-
diated hemolytic anemia (IMHA), severe metabolic
diseases and certain drugs administration.3,4,24,25
Reactive lymphocytes (plasmacytoid lymphocytes,
immunocytes and virocytes) are B-lymphocytes or
stimulated T-lymphocytes, which can normally be
found in low numbers in peripheral blood (com-
mon in young animals), but also in high numbers
in inflammatory diseases (especially in chronic dis-
ease). Additionally, the presence of medium or large
lymphocytes and mitotic figures can be the result of
reactive hyperplasia (Figure 3).2
Leukocyte inclusions are either of infectious or non-
infectious origin. The first category includes bacte-
rial, viral, protozoal and fungal diseases, whereas the
second includes immunological and hereditary dis-
eases affecting WBC morphology. Morulae of Ehrli-
chia canis, Ehrlichia ewingii and Anaplasma phago-
cytophilum are clusters of organisms that resemble
morulae and are stained magenta to blue-grey
with Romanowsky-type stains.2,4 They are observed
The interpretation of leukogram in dog and cat
Figure 4. Blood smear from
a dog with canine monocytic
ehrlichiosis. One monocyte
with a morula of Ehrlichia canis
(arrow) is witnessed. Giemsa,
100x objective.
infrequently and only during the acute phase of
the disease.3 Ehrlichia canis infects the monocytes
(Figure 4) and lymphocytes of dog, Ehrlichia ewingii
infects the granulocytes and rarely the monocytes
of dog and Anaplasma phagocytophilum can be
found in neutrophils and eosinophils.2 Gametocytes
of Hepatozoon canis are oval to elliptical, pale blue
and are seen in neutrophils and monocytes of dog.2
Canine distemper inclusions are red to pale blue
cytoplasmic inclusions that can be found during
the viremic stage of the infection in neutrophils,
lymphocytes and monocytes.2,3 Bacteria are rarely
seen in neutrophils of bacteremic patients, while
inclusions of infectious origin that are extremely un-
common findings in blood smears are Leishmania
spp. amastigotes, tachyzoites of Toxoplasma gondii,
Mycobacterium spp. and yeast phase of Histoplasma
capsulatum.2,4 Siderotic inclusions (or hemosiderin
granules) can be found, albeit rarely, in monocytes
or neutrophils in animals with hemolytic anemias
and they are represented by blue-green or yellow-
brown pigment on blood smears stained with Ro-
manowsky-type stains.2 The differentiation between
these inclusions and Döhle bodies relies on stain-
ing with Prussian blue (hemosiderin granules stain
positively).3 Infrequent findings of the microscopic
examination of blood are erythrophagocytosis and
lupus erythematosus (LE) cells. The former concerns
Hellenic Journal of Companion Animal Medicine • Volume 5 • Issue 2 • 2016 67
 The interpretation of leukogram in dog and cat
monocytes and neutrophils and is occasionally ob-
served in IMHA, while LE cells are neutrophils that
contain pink or pale blue inclusions (on Romanow-
sky-type stains) which vary in size and represent an-
tigen-antibody complexes.2 Hereditary disorders as-
sociated with WBC inclusions affect both dogs and
cats and are rarely seen in clinical practice. Chediak-
Higashi syndrome is characterized by large, lightly
eosinophilic cytoplasmic granules (Romanowsky-
type stains) that are contained in granulocytes.25
In hereditary anomaly of neutrophil granulation in
Birman cats, neutrophil cytoplasmic granules that
are stained deep pink to purple with Romanowsky-
type stains are seen and resemble the azurophilic
granules of promyelocytes.25 May-Hegglin anomaly
> References
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> Conclusion
In conclusion, the interpretation of leukogram con-
stitutes a valuable diagnostic tool for the clinician
since it contributes to the diagnosis, treatment and
prognosis of many diseases and pathologic states
of dogs and cats.
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